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SVC S C O T T I S HV E T E R A N SC O M M I S S I O N E R

Veterans’ Health & Wellbeing in Scotland– Are We Getting it Right?

AUGUST 2017

Contents

Introduction 4

Background 6

The Covenant and its commitments 7

A changing landscape 8

The ex-forces community 8

Health and social care needs of veterans 9

Protect what we have and prepare for the future 10

The Issues 11

The ‘promise’ 12

Rethinking priority treatment 13

Supporting those with severe and enduring conditions 14

Improving outcomes for all 15

Conclusions 16

Summary 17

Next steps 17

Get involved 18

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Introduction

Introduction

1 Transition in Scotland, 2015 : http://www.gov.scot/About/public-bodies/veterans-commissioner/Publications/TransitioninScotlandReport

It has been an enormous privilege to meet and represent the veterans community for the past three years as Scotland’s Veterans Commissioner.

During this time I have been looking at aspects of transition, housing and employability that impact most on the younger generation of veterans and their families. The positive responses to all three of my reports on these issues have been heartening. So too, has the progress that has been made by the Scottish Government and others in implementing the recommendations set out. Perhaps most rewarding, though, is the way in which these reports have helped promote an increasingly progressive approach towards veterans across Scotland. This is reflected by the shifting attitudes of many politicians, employers, the media and large sections of the general public.

My attention has now turned to a set of issues that affect all veterans regardless of age, background or personal circumstances: health and wellbeing.

In Scotland, we are fortunate to have outstanding public and third sector organisations that help keep our veterans and their families in good health. One of my earlier reports concluded that “veterans, and those transitioning from the military in Scotland, typically have access to a high standard of health care.”1

Since publishing that statement, I have heard many other positive comments about the quality of the treatment and care veterans receive from the National Health Service, Local Authorities and the numerous charities that work tirelessly in this sector. This is highly commendable and reassuring for those who decide to settle in Scotland after a career in the military.

That is not to say that veterans do not have specific medical and social care needs, nor to deny the fact that a small minority of them face considerable challenges when engaging with health and social care services.

Despite the overall positive picture, we cannot afford to be complacent. Nor should we ignore the opportunities that are emerging from changes within the NHS and an ever increasingly skilled charity sector. My primary aim, therefore, is to raise awareness of the need to protect the best of the current health and social care provision for veterans and to prepare for future needs.

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I have used these four questions as the starting point for my research and widespread engagement, which will continue in the coming months.

My second intent in publishing this ‘thought-piece’ is to initiate a debate in order to elicit responses and ideas from the many health professionals, officials, charities and veterans who are affected by, and understand, these issues.

Finally, I wish to start outlining some answers to these questions based on my work to date. These are not the conclusions of a health expert. They are my early impressions, formed with the help of the many individuals and organisations that have generously provided advice and information, without whom this work would not have been possible.

These impressions, along with continuing engagement and any responses to this paper, will be the basis of two subsequent reports with my detailed findings and a series of recommendations.

In the following chapters I explain the background and rationale before delving into the issues at hand and outlining my approach. Needless to say, I look forward to hearing from anyone with an interest in these issues.

Eric Fraser CBEScottish Veterans Commissioner

I have tried to identify what the measure of ‘getting it right’ should be, and have come up with four key questions:

Introduction

Are the health outcomes of our veterans population as good as they can be?

Does the health system properly fulfil our obligations to those veterans with the most severe and enduring illnesses and injuries acquired as a result of their military service?

Are the needs of our veterans population properly understood and considered by those who work in health and social care?

Do veterans face any disadvantages when accessing health and social care provision?

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Background

Background

The four fundamental questions outlined in the introduction (and repeated below) are largely drawn from a commitment already made to the armed forces community in the Armed Forces Covenant.

• Are the needs of our veterans population properly understood and considered by those who work in health and social care?

• Do veterans face any disadvantages when accessing health and social care provision?

• Does the health system properly fulfil our obligations to those veterans with the most severe and enduring illnesses and injuries acquired as a result of their military service?

• Are the health outcomes of our veterans population as good as they can be?

My hope is that these questions will help me assess whether we are successfully fulfilling the promises that have been made, as well as how we might better improve health outcomes for a community that makes up nearly 5% of Scotland’s population.

What is the Armed Forces Covenant?

At the height of the war in Afghanistan the UK Government published the Armed Forces Covenant – a promise from the nation and the government to its Service personnel, veterans and their families that they will be treated fairly and with respect. At its heart is the principle that the armed forces community should experience no disadvantage when accessing public and commercial services. The Covenant highlights that special consideration is appropriate in a minority of cases, quoting the injured and the bereaved as examples of this. It also makes provision for ‘priority NHS treatment’ for both serving personnel and veterans.

How is it implemented in Scotland?

The Scottish Government subsequently published a complementary strategy called ‘Our Commitments’ (2012) – recently updated in ‘Renewing Our Commitments’ (2016). Both documents set out the Government’s priorities and pledges to ensure that the armed forces and veterans community is properly supported and their contributions recognised. This includes commitments about meeting the community’s specific health and social care needs, including a commitment to ‘priority NHS treatment’.

What does it mean?

Our armed forces personnel defend our nation on behalf of government and its citizens, sacrificing civilian freedoms and putting themselves in danger to do so. The Covenant and Renewing Our Commitments, and the promises contained within, are significant expressions of both the UK and Scottish governments’ recognition of the sacrifices made by service personnel and the sometimes high levels of risk they have to counter. This is exactly as it should be.

THE COVENANT AND ITS COMMITMENTS

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A CHANGING LANDSCAPE

A lot has changed in Scotland since the Covenant and Our Commitments were published. In the areas of health and wellbeing, the most significant impact is the start of transformational change in NHS Scotland, namely the integration of health and social care and the establishment of local Integrated Joint Boards.

We have also seen the publication of several key strategies, such as the Healthcare Quality2 and Mental Health3 strategies that will have a direct and lasting impact on the way the veterans community is treated and cared for. These recent changes offer a timely opportunity to rethink and renew our commitments to veterans regarding their health and social care provision.

In many ways, the most important change in Scotland has come about as a result of the end of combat operations in Iraq and Afghanistan. As with previous conflicts, the public and media interest in the plight of those who made personal sacrifices has faded with the memories of war. This may be understandable. It is also frustrating to those with enduring physical, mental and social care needs whose suffering can be directly attributed to these wars.

For some time now I have sensed the need for a review of how we fulfil the pledges of the Covenant made to the men and women who defend our nation, sacrificing civilian freedoms and regularly putting themselves in danger to do so. The promises made must never be allowed to be forgotten, ignored or diluted.

THE EX-FORCES COMMUNITY

There are approximately 230,000 veterans in Scotland today, living in our largest cities, areas close to military bases and in the most rural and remote parts of our country. They range in age from 17 to 90+ and come from all social backgrounds, with those over 75 more than likely to have completed mandatory National Service.

Some will have served for up to forty years. Many more will have spent only a few years in uniform before returning to civilian life, while others will have even shorter service of only a few weeks or months. Very few of these veterans will be that different from the rest of the population. However, their experiences, attitudes and the consequences of their service often set them apart and may have a marked influence in later life.

Despite the public misconceptions on the topic4, veterans’ health is largely comparable to that of the general public. Even with regards to mental health, the assumption often made that veterans are disproportionately at risk of ill mental health is not supported by the evidence.

However, it is also important to understand that for those experiencing health issues, their needs can be different from those of the general population or they can be more at risk of certain issues as a result of their service history. In particular, there are a number of distinct groups within the veteran community who have specific requirements or are at higher risk of ill health.

Background

2 http://www.gov.scot/Topics/Health/Policy/Quality-Strategy

3 http://www.gov.scot/Resource/0051/00516047.pdf

4 A poll carried out by Lord Ashcroft in 2016 found that 9 out 10 members of the UK public expressed a view that “some kind of physical, emotional or mental health problem” must be common amongst veterans as a result of their time in the military. This was in direct contrast with serving personnel who felt that ill health was overestimated by the public. See http://www.veteranstransition.co.uk/vtrfollowupreport2_november2016.pdf

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HEALTH AND SOCIAL CARE NEEDS OF VETERANS The Covenant makes explicit mention of those severely injured in Service and the moral duty to meet their often complex and unique needs. This also applies to veterans who suffer from severe mental health conditions which have been caused, triggered or exacerbated by their service experience. In addition, some carers and the bereaved can face mental health issues, social isolation or loneliness as a result of the sacrifices made by their loved ones. The treatment, care and support of all these individuals should always be our top priority.

That being said, there are two groups within the community as a whole who are particularly at risk of poorer health outcomes.

Early Service Leavers are those who leave the armed services within four years of signing up, sometimes before completing training. It is generally well documented that they are the most vulnerable to ill health.5

The older generation of veterans, which includes many who did National Service, accounts for nearly half of Scotland’s veterans population. They are at increased risk of a number of health issues, when compared to non-veterans of the same age and background. Due to age, this is a group where common health concerns like hearing-loss, musculoskeletal issues, and diseases related to lifestyle factors, like smoking and alcohol consumption, can become more severe.5

This group is also at risk of greater social isolation and loneliness. I have spoken to many older veterans and have become increasingly aware of just how challenging some of these social issues can be.

Although at no higher risk, veterans settled in remote or rural parts of Scotland will often face challenges in accessing health and social care services. This issue has yet to be sufficiently addressed.

Background

5 Bergman, Beverly P. (2015) The Scottish veterans health study: a retrospective cohort study of 57,000 military veterans and 173,000 matched non-veterans, PhD thesis, URL: http://theses.gla.ac.uk/7144/ (last accessed 08/06/17).

PROTECT WHAT WE HAVE AND PREPARE FOR THE FUTURE The strong sense I get as a result of my engagement is that the overwhelming majority of veterans lead healthy, happy and productive lives. They are able to access the services they need and rarely report examples of coming up against disadvantage.

On the whole, they accept that health resources are finite and that tough decisions have to be made by politicians and officials alike. But I am also aware that many feel frustrated by a lack of clarity regarding the levels of treatment and support they can expect. This view is shared by many within the health sector.

There are a small number of veterans who are known to suffer from severe and enduring physical and psychological conditions that are attributable to their military service. Many – especially those wounded in recent wars – report good care and general treatment but they worry about its sustainability over a lifetime of need. There is also growing concern about the long-term provision of specialist services, especially in view of the diminishing public and media interest since the end of recent conflicts. This is particularly acute for those with mental health conditions which emerge many years after military service.

It is already clear to me that we need to acknowledge the quality of the services we have, protect them and prepare for future challenges in order to live up to the promises made by the Scottish Government.

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The Issues

In order to start answering my initial questions, I have considered how Scotland is currently fulfilling the promises made to veterans. Does the concept of priority treatment respond to the specific medical and social care needs of individuals and groups within our ex-Service community?

The Issues

THE ‘PROMISE’

The promises contained in both the Covenant and the Scottish Government’s complementary strategies are of huge importance to veterans and their families. I am pleased to say that the dedication and attitude of the health and social care sectors to those who have served very much upholds these commitments.

Here in Scotland, early responses to the Covenant allowed veterans to benefit from access to a number of specialised services over and above what might otherwise have been typically provided by the NHS. Examples include the dedicated prosthetics clinics in Glasgow and Edinburgh, the network of Veterans First Point (V1P) centres across Scotland and the residential mental health treatment at Combat Stress’ Hollybush House.

These and other initiatives go a good way to fulfilling our obligations to those veterans with the most severe and enduring illnesses and injuries, allowing them to access specialist and bespoke services. It is reassuring to have heard very few complaints about the quality or timeliness of this support over the past three years.

The Scottish Government has also introduced a number of measures to facilitate the transition into civilian life and to ensure that the long-term clinical needs of Service personnel and veterans are better understood and supported within the NHS. This positive and dynamic response to the Covenant has rightly attracted considerable recognition from across the UK.

Feedback received from all parts of the veterans community has typically been very complimentary about the dedication, resilience and professionalism of a National Health Service that faces considerable challenges. I would reiterate my view that veterans as a whole face no disadvantage when accessing health and social care services in Scotland.

That said, I am beginning to detect one or two concerns, and some criticism, that Scotland may be in danger of damaging its well-deserved reputation for being at the forefront of treating and caring for veterans. Although such views may be a little premature, this is a good time to re-examine our fundamental approach to the way we care for those who have served.

RETHINKING PRIORITY TREATMENT

NHS priority treatment (or care) for veterans, mentioned in the Covenant, dates back to 1953 and was originally restricted to war pensioners. Today, the idea is that veterans should receive priority treatment for health problems resulting from military Service, unless there is an emergency case or another case that demands clinical priority.

This is a particularly tricky concept which elicits some notably divergent and contentious views. For some, it is seen as an important benchmark that demonstrates the Government’s commitment to the health of its veterans. At the

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The Issues

other end of the spectrum, some regard it as little more than an abstract statement where the requirement to prove ‘clinical priority’ means veterans are treated no differently from anyone else by the NHS.

What has become apparent, though, is the serious lack of understanding about what it should deliver. This is despite concerted effort by both NHS Scotland and England to clarify the caveat of clinical need.

I am aware of a minority of individuals who understand the notion of priority care as an entitlement that provides veterans with preferential or faster treatment without regard to their individual clinical needs. This, in my view, is neither within the spirit of the Covenant, nor is it supported by the majority of those I meet. I accept there are occasional grumbles about delays in seeing consultants or other health professionals. But, this is not unique to veterans and often appears to be the result of limited capacity within the local health system.

This early work has led me to believe that the concept of priority treatment, as currently set out, is becoming out-dated and is certainly misunderstood or ignored by large sections of the military, veterans and medical professionals - as well as the general public. It may be that it has served its original purpose and the time is right for an honest appraisal of how effective and relevant it is today, especially now that NHS quality standards have tailored waiting times for everyone to their clinical need.

I have come to the conclusion that we could all benefit from a much clearer understanding of the concept, an open debate about its relevance, and an exchange of ideas about how it might be improved.

SUPPORTING THOSE WITH SEVERE AND ENDURING CONDITIONS

Veterans are a diverse sub-section of society. Those with severe and enduring health issues acquired as a result of their military service – often colloquially known as the ‘Wounded, Injured and Sick’ – is one group that stands out starkly. Their lives have been permanently affected by injury or illness, sometimes as a result of enemy action but just as often caused by peacetime accidents.

The overall number of men and women who are affected is thankfully small but they have sacrificed the most. In accordance with the Covenant, they deserve the best possible medical and social care – both now and over the long-term.

This group will be the focus of a subsequent report. Amongst other issues, I will review the sustainability of the impressive bespoke care currently available to those with prosthetics, severe mobility issues, and mental health conditions. I am also keen to explore the opportunities offered by the current integration of health and social care, a growing emphasis on a more holistic approach to care, and the greater role that can be played by allied health professionals in improving the overall quality of life and wellbeing.

I do not anticipate that protecting the best of the current specialist services requires a large investment of new resource. I do, though, think it is crucial to ensure that this provision is protected in the medium to long-term and that the evolving needs of this group of veterans is part of a strategic plan.

The good news is that initiatives like these feature heavily in the Scottish Government’s Healthcare Quality Strategy and are already being discussed and implemented for the wider population as a result of its consultation on Creating a Healthier Scotland. The trick may be to ensure that the care regime for this very specific group of veterans becomes an integral and enduring, if small, part of the overall health system in Scotland.

Finally, I want to highlight the plight of the families of those affected by Service-related injuries or illnesses as well as the bereaved who have lost loved ones. Caring for someone with a disability, growing up around a parent who

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The Issues

cannot work or losing a loved one is a heavy and far-reaching sacrifice, which creates many and often invisible challenges. Here, too, it is important that their personal sacrifices are recognised and that they always have access to support which is tailored to their needs.

I strongly believe that providing these groups with the best possible treatment and support should be the focus of our efforts and our strategic priority.

IMPROVING OUTCOMES FOR ALL

Having rightly focused on those veterans with severe and enduring conditions, I am also determined not to lose sight of the health and social care needs of the wider ex-Service population. In a separate report, I will explore some of the bigger challenges they face but I already sense there is more that can be done to improve their overall health and wellbeing.

While the types of illnesses affecting veterans may vary in severity, very few are likely to be unique to this group and it may be difficult to prove any sort of direct and unambiguous connection with military service. That said, recent studies have gone some way in identifying a number of conditions that are more prevalent amongst veterans than their non-veteran counterparts. These include:

• hearing loss - from regular exposure to extreme noise,

• musculoskeletal problems, such as arthritis - after a physically demanding career, and

• alcohol and smoking-related diseases - often linked to cultural lifestyle factors such as access to cheap cigarettes and smoking and drinking in the mess decks or barracks.

Such work has significant potential in helping the medical profession identify, prevent and provide early treatment which will, ultimately, be of lasting benefit to veterans and their families. It will also be in keeping with the broader approach of NHS Scotland with its emphasis on patient-centred, holistic care. I am looking forward to exploring this further as part of the next phase of my work.

There are other aspects of treatment and support for the wider veterans community that have been suggested for further study. One example, which has been raised repeatedly by researchers and veterans alike, is the particular challenges faced by certain demographic groups. This includes Early Service Leavers, the older generation of veterans and those who live in remote or rural areas. I believe a better understanding of these groups – and of a life in the Armed Forces – would be of significant benefit to GPs, Practice Nurses and other professionals when managing the overall health of veterans in their communities. This is already recognised in some geographical areas but I sense there is scope to share good practice more widely and to further encourage health professionals to consider veterans as a distinct group with particular vulnerabilities.

Given that there is wide acceptance in Scotland that better education, screening and early intervention will invariably lead to improved health outcomes, it seems entirely logical that this should be applied to our veterans community with its own characteristics and needs.

The next phase of this study will also provide the opportunity to examine whether the right structures and processes are in place to ensure veterans can access health and social care services as easily as possible. An example of this includes the procedure for registering at a GP practice upon leaving the Services. On first examination, this should be a relatively straightforward step but a minority of mostly younger veterans fail to follow it and rely instead on A&E or walk-in clinics with its consequent inefficiencies and costs. Regrettably, those who fail to enrol are often amongst the most vulnerable and this puts them at an obvious and considerable disadvantage.

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The Issues

Similarly, veterans and medical professionals continue to report complications and delays when trying to obtain patient records. This seemingly simple procedure is proving especially hard to resolve despite sustained efforts to give the NHS – and GPs – full and seamless access to veterans’ medical records. The introduction of new IT equipment and data sharing issues compound a problem which causes serious frustration for many. A solution needs to be found without further delay and I will be keen to hear ideas as to how this problem might be addressed.

Finally under this section, I intend to examine the governance arrangements within the Scottish Government and NHS Scotland as they relate to veterans, and their ability to work collaboratively with the third sector. Both aspects will be vital for the long-term future of veterans health and wellbeing. The good news is that there is already a national policy framework in Scotland to facilitate much of this; the challenge may be to integrate veterans health as part of the wider NHS without diminishing or overlooking their specific nature and needs.

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Conclusions

SUMMARY

I have produced this paper in the hope of stimulating interest and debate around the issues of veterans’ health and wellbeing in Scotland. It deliberately does not include recommendations at this stage but it ‘sets the scene’ and I hope illustrates an appropriate level of ambition for the treatment and care of Scotland’s ex-Service community.

The points raised are the result of an extensive period of engagement with a wide range of stakeholders, mainly in Scotland but also from other parts of the UK. Many of the issues will lead to further investigation but these initial studies have already led me to conclude that:

• The vast majority of veterans in Scotland are in relatively good health and lead happy and productive lives.

• On those occasions when they need access to health or social care services, they rarely report obvious disadvantage when compared to the non-veterans population and are content with the support they receive.

• There remains a strong moral case for ensuring that the risks faced, and the sacrifices made, by Service personnel in protecting us are properly recognised and that all those who suffer injury or illness as a result are cared for appropriately. The Armed Forces Covenant and the Scottish Government’s Renewing Our Commitments are central to ensuring this happens.

• Veterans and family members with the most severe and enduring illnesses and conditions that have arisen from their military service deserve the best possible treatment, care and support. This should be our highest priority.

• Scotland is fortunate to have some outstanding statutory and charitable services that provide much needed specialist treatment, care and support for the small number of veterans who have given so much and suffer the most serious and life-changing illnesses and/or injuries.

• The provision of these specialist services and the principles of the covenant must be protected for both current and future generations of veterans. Decision-makers must also plan strategically to prepare for the longer-term needs of this community, including for current service users as they grow older.

• For the wider veterans community, there is still more that can be done to improve their overall health outcomes. Much of this is likely to involve relatively minor administrative and procedural changes, greater emphasis on prevention and better understanding of veterans and their needs. This is also likely to be in line with the overall approach taken by the NHS in Scotland.

• Perhaps more controversially, there needs to be an open debate about the concept of ‘priority treatment’ and whether the current emphasis on waiting lists provides a meaningful measurement of its efficacy. My growing conviction is that this may no longer be valid and I see far greater benefit from focusing on the principles of excellent, accessible and sustainable treatment and care for all veterans. I want to be clear that in concluding this, I am absolutely not advocating any lessening of the provision for veterans; in fact, quite the contrary.

Conclusions

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NEXT STEPS

Subject to the responses I receive to this paper, I will follow it up with two detailed reports over the coming months. The first will look more closely at that mercifully small group of veterans who have suffered life-changing injuries or illnesses as a result of their military service and will need life-long support. The second paper will examine the broader health needs of the veterans community, focussing on improving overall health outcomes and access to services for the wider population of veterans. These reports will contain recommendations to the Scottish Government and its partners across the health and veterans sectors.

I urge anyone with an interest in, or ideas about, the treatment, care and support that is provided to the veterans community to get in touch with your feedback and/or suggestions. I would particularly appreciate hearing examples of what works well, as I am keen to feature ‘good practice’ in the next two reports. It is also important that I hear from anyone who has examples of what doesn’t work so well and has ideas for how to make improvements.

GET INVOLVED

Conclusions

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